Comparative Effectiveness of Bariatric Surgeries in Patients with Type 2 Diabetes Mellitus and BMI ≥ 25 kg/m2: a Systematic Review and Network Meta-Analysis

PURPOSE

In patients with type 2 diabetes mellitus (T2DM), bariatric surgery appears to be more effective than medical treatment (MT) at improving glycaemic control and decreasing cardiovascular risk. However, long-term effectiveness has not been systematically assessed using randomised controlled trials. In this study, we aimed to systematically assess randomised controlled trials, with at least 5 years of follow-up, on bariatric surgery in patients with T2DM and BMI ≥ 25 kg/m², as well as to compare different bariatric procedures.

MATERIAL AND METHODS

PubMed, SCOPUS and Web of Science were searched. We performed a network meta-analysis to evaluate the comparative effectiveness of the different procedures and MT in terms of full T2DM remission, weight loss, complications and cardiometabolic biomarkers. The quality of evidence was assessed using the Cochrane Risk of Bias Tool and CINeMA.

RESULTS

We included 11 primary studies. Laparoscopic one-anastomosis gastric bypass (LOAGB) was found to be one of the most effective treatments for full remission of T2DM (I² = 0, inconsistency p value = 0.9223). Biliopancreatic diversion without duodenal switch was found to be more effective than laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding regarding percent total cholesterol and low-density lipoprotein change. Regarding percent high-density lipoprotein and weight change, all analysed surgical treatments were shown to be more effective than MT. The confidence rating in our results was overall moderate, but most studies had high risk of performance and detection bias.

CONCLUSION

Bariatric surgery seems to be effective for T2DM remission. LOAGB appears to be a good option in this context, and a possible alternative to laparoscopic duodenal switch, but the included primary studies in our review are not sufficiently powered to establish a more definitive conclusion. More studies with longer follow-up times are needed to comprehensively assess bariatric surgery in T2DM.

Three-trocar laparoscopic duodenal switch after sleeve gastrectomy

Laparoscopic duodenal switch is a recognized bariatric procedure, which can be performed in one step or as a second step after laparoscopic sleeve gastrectomy (LSG). Mainly, indications as primary surgery are super-obese or super super-obese patients, and after LSG indications are the presence of insufficient weight loss or weight regain, associated with morbid obesity co-morbidities, without gastroesophageal reflux. In this video, the authors report the technique of reduced port laparoscopic duodenal switch after LSG. The procedure is performed using a 12-mm trocar in the umbilicus, a 5-mm trocar in the right flank, and a 5-mm trocar in the left flank. One or more temporary percutaneous sutures are passed into the hepatic ligaments to increase the exposure of the first duodenum. The optical system is switched from 10 mm to 5 mm and introduced in the left 5-mm flank trocar at the step of the linear stapler insertion through the umbilical trocar. Classic construction with 150-cm alimentary limb and 100-cm common limb is performed. The duodeno-jejunostomy is fashioned in an end-to-side handsewn technique and the jejuno-ileostomy in the side-to-side semimechanical linear stapler technique. Both Petersen and mesenteric defects are closed. The umbilical access is finally meticulously closed, avoiding incisional hernia. Reduced port laparoscopic duodenal switch after LSG is a safe and feasible technique. Besides the enhanced cosmetic outcomes, this surgery is associated with a reduced use of painkillers, fewer trocar complications, and quick patient convalescence.